What are the steps for wound care? 2. Gather supplies and prepare a clean work area 3. Perform hand hygiene and don gloves 4. Inspect wound for signs of infection 5. Cleanse wound from center outward using NSS 6. Apply prescribed medication 7. Apply sterile dressing 8. Secure dressing in place 9. Dispose of supplies and perform hand hygiene

2. Skin: structure and function
General Functions
Each skin layer has its own unique function
􀁺 Epidermis = protection
􀁺 Dermis = nourishment of epidermis
􀁺 Hypodermis = Composed mostly of adipose tissue
insulation

4. Skin: structure and
functiontissues from:
Protects deeper
Mechanical damage ( bumps & cuts)
Chemical damage (acids & bases)
Bacterial damage
Thermal damage (heat & cold)
Ultraviolet radiation (sunlight)

5. Classifying wounds
A wound can be defined as:
“A cut or break in the continuity of any tissue,
caused by injury or operation”
(Baillière’s 23rd Ed)

6. Wound Types and
Characteristics
CLOSED
Contusion ( Bruise) – Tissue injury without
breaking of skin.
CD: Purpule contusion 5x7 cm on left face
Hematoma – Tissue injury that disrupts a
blood vessels; pooling of blood under the
unbroken skin
CD: 2 in diameter hematoma on left face

7. Sprain – Wrenching or twisting of a joint
with partial rupture of its ligaments;
causes swelling
CD: Swelling of right foot and round
malleolus. No bruising noted
OPEN
Incision- Surgically made separation of
tissues with clean, smooth edges
CD: Approx. 3-in incision on R lower
quadrant of abdomen; well approximated;
clean and dry with sutures intact

8. Laceration – Traumatic separation of
tissues with clean, smooth edges
CD: 2 in jagged (pointy, uneven)
laceration app 4 cm deep on L sole
foot.
Abrasion- Traumatic scraping away of
surface layers of skin
CD: Raw appearing abraded area 2 1/2
in diameter on lateral aspect of lower
leg.

9. Puncture – Wound made by sharp, pointed
object through sin or mucous membranes
and underlying tissue.
CD: Small circular entry wound on R palm
from sharp pointing nail
Penetrating- Variable – size open wound
through sin and underlying tissues made
by a bullet or metal or wood fragment; may
extend deeply into body
CD: Jagged Deep wound 10 in posterior on
L leg.

10. Avulsion – Tearing away of a structure or
a part, such as a fingertip, accidentally or
surgically.
CD: Avulsion of L leg from VA. Attach only
by skin.
Ulceration – Excavation of sin and/or
underlying tissue from injury or necrosis
CD: Ulceration on L sole foot 4 cm x 5 x 2
cm deep. Yellow drainage present.
Wound edges reddened.

11. Wounds can be classified according to their nature:
•

12. 2. According to depth
Superficial
Involves only the epidermis
Injury is usually the result of fiction, shearing (cut) or
burn.
Partial Thickness
Involves the epidermis and the dermis
Wounds heal more quickly
Full Thickness
Involves the epidermis, dermis, fat, fascia and exposes
bone
In order to heal, all dead tissue must be removed so
that granulation tissue can gradually fill in the defect.

13. TYPES OF WOUND DRAINAGE
 Serous -clean, watery
 Purulent - thick, yellow, green, tan or
brown.
 Sanguineous - bright red, indicative of
active bleeding.
 Serosanguineous -pale, red, watery
mixture of serous and sanguineous.

14. Wound healing
All wounds heal following a a specific
sequence of phases which may overlap
The process of wound healing depends on
the type of tissue which has been damaged
and the nature of tissue disruption
The phases are:
Inflammatory phase
Proliferative phase
Remodeling or maturation phase

15. PHASES OF WOUND HEALING
1. INFLAMMATORY PHASE
-starts immediately after injury and lasts 3-6
days or 4-6 days.
2 major processes occur during this phase …
HEMOSTATIC AND PHAGOCYTOSIS
Haemostatic
- Tissue and capillaries are destroyed, plasma and
blood leaks. Area blood vessels constrict, platelets
aggregates and bleeding stops, scabs ( rough
protective crust) forms, preventing entry of
infectious organisms.

16.  Inflammation
Characterized by edema, erythema, pain,
temperature
- increase blood flow, to wound resulting
localized redness and edema, attracts
WBC and wound growth factors.
 WBC arrive-clear debris from wound.

17. injury
Exposure of plasma to
injured site Release of Histamine
Activation of Hageman Factor Capillary Permeability
Vasodilation
Kinin Prostaglandin
Edema Inc bld Flow
Clotting
Tumor Rubor
Dolor ( Swelling) (Redness)
( Pain)
Calor
( Heat)

18. 2. PROLIFERATIVE PHASE
-extends from day 3 to about day 21 post
injury.
Macrophages continue to clear the wound
debris, Stimulates Fibroblast to synthesize
collagen 9 main ingr. For tissue scaring)
New capillary networks are formed.

19. 3. REMODELLING OR MATURATION PHASE
-final healing stage may continue for I year
or more.
Remodeling of scar tissue to provide wound
strength.

20. TYPES OF WOUND HEALING
 FIRST INTENTION HEALING-partial
thickness wounds.
- a clean incision is made with primary
closure, minimal scarring.
-expected when the edges of clean surgical
incisions are sutured together, tissue loss
is minimal or absent if the wound is not
contaminated with microorganism.
-e.g.-abrasion or skin tear.

21.  SECOND INTENTION HEALING
-granulation
-accompanies traumatic open wounds with tissues loss or
wounds with a high microorganisms count.
-go though a process involving scar tissue formation a heal
slowly because of the volume of tissue needed to fill the
defect.
-e.g.-contaminated surgical wound, pressure ulcer.
Delayed primary healing
If there is high infection risk – patient is given antibiotics
and closure is delayed for a few days e.g. bites

22. Factors affecting healing

23. Wound can result from:
Planned events – Such as surgery
Accidents – such as a fall from a bike
Exposure to environment – such as the
damage to UV rays in sunlight.

24. Clinical appearance
Describes the type of material present
In the base of the wound:
Slough (yellow)
Necrotic tissue (black)
Infected tissue (green)
Granulating tissue (red)
Epithelializing (pink)

25. Sloughy wound
• Aim: to liquefy slough and
aid its removal
• Dead cells accumulated in
exudate
• Prepare wound bed for
granulation
• Assess wound depth and
exudate levels
• Hydrogels, hydrocolloids,
alginates and hydrofibre
dressings

26. Necrotic wound
• Aims: to debride and
remove eschar
Provide the right
environment for
autolysis
• Assess wound
depth and
exudate levels
• Hydrogels,
hydrocolloid
dressings

27. Infected wound
• Aims: reduce exudate,
odour and promote
healing
Clinical signs of
infection
Swab wound – systemic
antibiotics
Treat symptomatically:
exudate and odour
control
Change dressings daily

28. Granulating wound
• Aims: support
granulation, protect new
tissue, keep moist
Assess depth and
exudate levels
Moist wound surface –
non-adherent dressing
Treat over-granulation
Hydrocolloids, foams,
alginates

29. Epithelialising wound
• Aims: to provide suitable conditions for
re-surfacing
, films, hydrocolloids
Disturb as little as possible

30. COMPLICATIONS OF WOUND HEALING
 1. HEMORRRHAGE
-risk of hemorrhage is greatest during the ist
48 hours after surgery.
-emergency -N@- should apply pressure
dressing to the wound and monitor vital
signs.
 2. INFECTION
-surgical infection is apparently 2-11 days
post operatively.

31. N@- watched for presence of changed in
wound color, pain or drainage-culturing of
the wound.
 3. DEHISCENCE WITH POSSIBLE
EVISCERATION
-may occur 4-5 days postoperatively.
-involves an abdominal wound in which the
layers below the skin separates.
N@- an increase in flow of serosanguinous
drainage into the dressing can indicate

32. impending dehiscence.
- If occurs N@ should be quickly
supported by sterile dressing soaked in
sterile normal saline.
-position? Client in bed with knees bent…
why? To decrease pull on the incision. and?
Notify physician……

33. Infected wound dehiscence

34. Wound assessment
Lab tests: Etiology
Signs of
infection Size, depth
& location
Odour or WOUND
exudate ASSESSMENT
Wound bed:
• necrosis
Wound edge • granulation
Surrounding skin:
colour, moisture,

35. WOUND MANAGEMENT
 1. DRESSINGS - material applied to wound
with or without medication, to give
protection and assist in healing.
-what are the purposes?
To protect the wound from mechanical injury
Splint or immobilized the wound.
Absorbs dressing
Prevent contamination from bloody
discharges

36.  Promote homeostasis, (pressure
dressing)
 Debride the wound
 to kill or inhibit microorganism
 provide a physiologic environment
conducive to healing
 provide mental and physical comfort for
the patient.

37. Pressure dressing

38. What are the types of dressings?
a. DRY TO DRY DRESSINGS
-used primarily for wounds closing by
primary intention.
-offers good protection, absorption &
provide pressure
-they adhere to the wound surface when
drainage dries.
- when remove can cause pain and
disruption of granulation tissue.

39.  b. WET TO DRY DRESSINGS
-used for untidy or infected wounds that must
be debrided and closed by secondary
intention.
>how can it be done?
-gauze saturated with sterile saline or
antimicrobial sol’n. is packed into the wound,
the wet dressing are then covered by dry
dressings
>when to changed?
-when it becomes dry

40.  c. WET TO WET DRESSINGS
-used on clean open wounds or on
granulating surfaces.
-provide a more physiologic environment
(warmth moisture) which can enhance the
local healing processes and assure greater
patient comfort.
-surrounding tissues can become ulcerated.
high risk for infection.

41.  2. DRAINS- device or a tube used to draw
fluids from an internal body cavity to the
surface.
-what are the purposes?
a)placed in the wounds only when
abdominal fluid collections are present.
b)placed near the incision site
> wound drainage-drains placed within the
wounds are attached to a portable suction
with a collection container.
e.g. hemovac, jackson-pratt, penrose drain.

42.  3. BINDERS AND BANDAGES
-what are the purposes?
Creates pressure over the body parts
Immobilize body parts
Reduce or prevent edema
Secure a splints
Secure dressing

43. Dressing choice
What is available?
How do we choose?
Does the patient have a say?
Do we consider cost?
Are choices restricted by a protocol?
How do we evaluate?

44. Dressing
A process of cleansing the wound using
aseptic solution.
∆ To aid debridement The ideal dressing
∆ To remove excess • A dressing that
exudate creates the optimum
∆ To control bleeding environment
∆ To protect a wound • Wound debridement
∆ To support healing • Wound cleansing
• Alternative therapies

45. TYPES OF DRESSINGS
Hydrogel Dressings
Hydrogels are indicated for management
of pressure ulcers, skin tears, surgical
wounds, and burns, including radiation
therapy burns. Because they contain up
to 95% water, hydrogels cannot absorb
much exudate and should be reserved for
dry wounds or wounds with minimal to
moderate drainage.

46. Hydrocolloid Dressings
Because they are occlusive, hydrocolloid dressings do
not allow water, oxygen, or bacteria into the wound.
This may help facilitate angiogenesis and granulation.
Hydrocolloids also cause the pH of the wound surface
to drop; the acidic environment can inhibit bacteria
growth.
Like hydrogels, hydrocolloids can help a clean wound
to granulate or epithelialize and encourage autolytic
( distruction of cells by own enzymes) debridement in
wounds with necrotic tissue. However, because of
their occlusive nature, hydrocolloids cannot be used if
the wound or surrounding skin is infected.

47. Alginate Dressings
Previous columns have addressed products that are
appropriate for dry wound beds or wounds with minimal
exudate or drainage-namely, hydrogels and
hydrocolloids. In contrast, alginate dressings absorb
moderate to high amounts of wound drainage.
In wounds with moderate to heavy drainage, the alginate
forms a gel when it comes in contact with wound fluid.
Capable of absorbing up to 20 times its weight in fluid, an
alginate can be used in infected and noninfected wounds.
Because an alginate is highly absorbent, it should not be
used with dry wounds or wounds with minimal drainage; it
could dehydrate the wound, delaying healing.

48. Composite dressings
Made of three layers. The layers of the composite dressings combine to
form an antimicrobial barrier for moderate to heavy exuding wounds. Some
composite dressings also gradually release silver over time to promote
healing. Our selection of silver dressings include the popular Acticoat,
Aquacel and Aquacel AG.
Composite dressings have multiple layers and can be used as primary or
secondary dressings. They are appropriate for wounds with minimal to
heavy exudate, healthy granulation tissue, necrotic tissue (slough or moist
eschar), or a mixture of granulation and necrotic tissue
Use composite dressings cautiously if the patient is dehydrated or has
fragile skin. Keep in mind that some insurers will not reimburse a facility
or provider if a composite dressing is used as a secondary dressing with a
hydrogel or impregnated gauze.

50. Transparent Films
Film dressings are flexible sheets of transparent
polyurethane coated with an acrylic adhesive. They
can be used as a primary or secondary dressing.
These dressings are semipermeable, vary in size and
thickness, and have an adhesive that holds the
dressing on the skin. They conform easily to the
patient's body but do not hold well in high-friction
areas, such as the sacrum or buttocks.
Because films are transparent, the wound can be
easily monitored.
Because films are semiocclusive and trap moisture,
they allow autolytic debridement of necrotic wounds
and create a moist healing environment for
granulating wounds.

51. Principles
Explain the procedure to the patient
Handwashing before and after the
procedure
Clean from least contaminated to the
most contaminated area
Use separate cotton for each stroke
Start from the center going outward
• Observe aseptic technique

52. Equipment
Sterile gloves Cotton balls with
Picking forcep cleanser
Dressing forcep Cotton balls with
antiseptic
Bandage scissor
Normal Saline
Adhesive tapes
Solution (NSS)
Dry cotton balls
Waste receptacle
Sterile gauze

53. Procedures
1. Check physician's order for specific
wound care and medication instructions.
 Helps to plan for proper type and amount of
supplies needed.

54. Procedures
2. Secure equipment and wash hands
thoroughly.
To save time and effort. Reduces
transmission of pathogen

55. Procedure
3. Assess the existing dressing
Indicates types of dressing or applications
to use.

56. Procedure
4. Explain the procedure to the patient
and instruct client not to touch wound
area or sterile supplies.
 Decreases anxiety and to gain cooperation.
Sudden unexpected movement on client's part
could result in contamination of wound and
supplies.

57. Procedure
5. Loosen and remove the dressing with the use of the
dressing forcep. If the dressing adheres to the
wound, loosen it by moistening with sterile NSS.
 Microorganism can be transferred by direct contact from
dressing to hands. An intact scab is a body defense and
can be damage if not handled gently.

58. Procedure
6. Observe the dressing for the amount
type, color and odor of the drainage.
 Provides estimate of drainage
amount and assessment of wound's
condition.

59. Procedure
7. Discard the soiled dressing in the
waste receptacle.
Reduces the transmission of
microorganism.

60. Procedure
8. Clean the wound aseptically using the
dressing forcep from the center going
outward in circular motion with;
A.Betadine cleanser
B.Dry gauze
C.Betadine antiseptic solution
(use each gauze for only one stroke)

61. Procedure
Prevents contamination of previously cleaned.
Prevents introduction of organism into wound.
Reduces excess moisture, which could
eventually harbor microorganism.
Helps reduce growth of microorganism

62. Procedure
9. Apply a new dressing by gently placing
the gauze sponges at the wound center
and moving progressively outward to
the edges of the wound site.
Promotes proper absorption
of drainage and protects wound
from entrance of
microorganism.

63. Procedure
10. Secure the edges of the dressing to
the patient’s skin with strips of adhesive
tapes.
Ensures that dressing remains intact and
covers wound.

64. Procedure
11. Make the patient feel comfortable and
tidy the unit.
Promotes client's sense of well-
being. Enhances comfort.

65. Procedure
12. Do the aftercare of the equipment.
Soak the dressing forceps in 5% lysol
solution for 30 minutes, then wash them
with soap and water. Rinse them then
dry. Send them to the CSR for
sterilization..

66. Procedure
13. Wash hands.
Prevent spread of microorganism.

67. Procedure
14. Chart: site of wound, character
of wound/ discharges, treatment
given if any(e.g. ointment used)
and reaction of patient.
For proper documentation and legal
purposes

68. Reference
Fundamentals of Nursing, fifth edition, page
1598-1605 by Potter and Perry
http://images.google.com.ph/imgres?img
Fundamentals of Nursing, seventh edition,
page636-645 by Wolff
Fundamentals of Nursing by Kozier

69. Questions???

70. Wound evisceration from
stab wound

71. Wound dehiscence